PONE-D-24-24159The mediating role of depression on the link between physical activity and health-related quality of life among people with diabetes: A cross-sectional studyPLOS ONE

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The study assessed the mediating effect of depression on the relationship between physical activity and health-related quality of life among people with diabetes. The study has added knowledge. Few comments for the authors.

Abstract

i. "decreased health-related quality of life (HRQoL) and physical activity". This phrase looks contradictory to what is known. You either remove the word 'decreased' or changed 'PA' to physical inactivity.

ii. "In individuals with diabetes, depression was found to moderate the effect of PA on HRQoL." Change moderate to mediate.

Introduction

i. " Lastly, there is a lack of research investigating potential mediators, such as depression, with individuals with diabetes two- to three-fold more likely to experience depression. The last part of the sentence needs referencing.

ii. "Several studies have shown depression to have a partial mediating effect on the relationships between HRQoL and

neuropathic pain, atrial fibrillation, and cardiovascular disease." Please reference 2-3 of these studies.

Statistical analysis

" These moderated mediation models included regular exercise, walking, and PA as independent variables, depressive symptoms as mediators, and HRQoL as the dependent variable." What variable serves as moderator(s)?

Results

i. Tables 1-3 are missing.

ii. Fig 3: It seems three sets of mediation analyses were performed. PA, Walking and RE were entered separately as an independent variable. Under the analysis section, you stated MEDMOD model was used suggesting walking and RE were moderators while depression was mediator. PA as independent and HRQoL as dependent variables. Please clarify.

Conclusion

There is a difference between mediator and moderator. Please be consistent in the usage. You set out to find out the mediating effect of depression on the relationship between PA and HRQoL. Please change moderating to mediating.

See other comments in the attached.

Reviewer #2: Well-written manuscript with with an adequate justification and good methodology. The conclusions were fair.

Minor corrections

Introduction

• Provide reference for line 40 (sentence starting with “However…..”)

Ethical consideration

Line 184: check the spelling of ‘providesd’

Results

Lines 196-197: The sentence starting with “Regarding PA levels….) must be rephrased to make the meaning clearer

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: PONE-D-24-24159.pdf

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Submitted filename: Reviewer Comments.docx

The mediating role of depression on the link between physical activity and health-related quality of life among people with diabetes: A cross-sectional study

PONE-D-24-24159R1

Dear Sanghee Kim,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Md. Feroz Kabir, BPT, MPT, MPH, BPED, MPED

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Submit your revised manuscript as the reviewers comments within the next 10 days.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #4: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #4: No

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #3: (No Response)

Reviewer #4: I belive the authors did great work but I have some comments that need to be addressed:

method:

The inclusion/exclusion criteria are well-defined, but the choice to exclude respondents based on missing data on PA and alcohol consumption could be more justified. For example, did the authors consider any potential bias from these exclusions?

The description of how depressive symptoms were measured ("sadness or unhappiness for more than two weeks") might benefit from elaboration. A discussion on the validation of this question as an adequate measure of depression could strengthen this section.

statistical analysis:

There is some ambiguity in the choice of covariates. While most of the covariates seem appropriate, variables like "suicidal thoughts" (Table 1) may require additional justification for inclusion. How might these impact PA and HRQoL? A brief explanation would be helpful.

In Table 3, the confidence intervals for the indirect effects appear quite narrow. It would be helpful to confirm if the bootstrapping method was used, as it’s typical in mediation analyses to ensure robustness of the estimates.

Results:

The sentence regarding the mediation analysis results (lines 250-251) could be made clearer. For example, explicitly stating how the interpretation of the mediation effects was determined (e.g., via statistical significance, magnitude of effect size) would clarify the importance of these findings.

The gender-specific analysis (Figure 2) provides interesting insights but could be expanded upon in the discussion. Gender differences in HRQoL and depression should be explored further in relation to physical activity.

discussion:

While the discussion addresses the core findings well, it would benefit from a deeper exploration of the clinical implications of the mediation results. For instance, what are the practical steps clinicians could take to reduce depression and improve HRQoL through PA interventions in this population?

The limitations are appropriately acknowledged, particularly regarding the cross-sectional nature of the study and the reliance on self-reported data. However, the potential for residual confounding should also be mentioned, as it is possible that other unmeasured factors may influence the relationship between PA, depression, and HRQoL.

conclusion:

The conclusion might benefit from a clearer call to action for future research. Given the cross-sectional design, a suggestion for longitudinal studies or interventions aimed at directly testing the effects of PA on depression and HRQoL would be valuable.

lastly:

Acknowledging that the data were collected during the COVID-19 pandemic and associated restrictions is important, as it could have influenced several variables in your study, such as physical activity levels, mental health (including depression), and overall quality of life.. limitations section (after line 338) you should include something regards that..

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #3: No

Reviewer #4: No

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